Fill Out Form Below For Free Marriage or Family Counseling

*If you have ever received counseling/psychiatric services,
please describe:

Level of completed education:

Occupation:

*If you are taking any medications, please list name and dosage:

*Describe the problem below, providing
as much information as possible:

Terms of Use Agreement

Please read the following, then click on "Submit" to send your information. By clicking Submit you are agreeing to the "Terms of Use Agreement."

You must be over 18.

People experiencing suicidal feelings, crisis situations, alcoholism, drug abuse, various types of abuse, violent relationships, eating disorders, and severe mental illnesses should work with a face to face therapist. For emergency help call 911, or go to your nearest hospital emergency room, or call the national Suicide Hotline at 1-800-SUICIDE.

By using these services you acknowledge the limitations inherent
in ensuring client confidentiality of information transmitted through the Internet and by telephone.

By using these services you agree to Pastoral Biblical Counseling.

I will keep our correspondence secure on my own personal computer.
All information is kept confidential with the exception of legal requirements to report child abuse, danger to others or danger to self.

If your problem is beyond my scope of expertise, I will immediately
inform you of such.

BY CLICKING SUBMIT FORM I UNDERSTAND AND AGREE TO THE TERMS OF USE AGREEMENT.

Crisis Family Care will NEVER abuse your trust
by sharing your e-mail address or any other personal information without your explicit consent.